A 73-Year-Old Man With Subacute Onset of Diplopia

Introduction. A 73-year-old man describes subacute onset of diplopia (double vision) occurring for several weeks.

Patient history. The patient noted that the episodes of diplopia were more common later in the day. He has stopped driving at night. The ocular symptoms became most apparent on the senior softball field, when the patient started missing routine flyballs and striking out more frequently. After striking out three times in one game, his teammates inquired about his vision and cautioned him not to play until he had obtained medical advice.

His physician obtained the above history, and on further physical examination, noted drooping eyelids as well as additional symptoms, including jaw fatigue when chewing. His ocular symptoms and jaw weakness worsened as the day proceeded after being absent or minimal upon awakening.

Physical examination. The patient’s physical examination revealed dropping eyelids, but his vital signs were within normal ranges. There were no signs of nystagmus, and his masseter muscle strength seemed to be within normal range as well. There was no proptosis or thyroidomegaly. His chest and abdomen findings were also within normal ranges. On neurological examination, his deep tendon reflexes were all present, and there were no sensory deficits, nor any other findings of note.

A physician teammate performed a repetitive grip test but could not elicit progressive weakening or fatigue. Still, the physician believed that repetitive strong blinking likely worsened the drooping of the eyelids.